USCDI Export for the Public

Classification Level Sort descending Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Issuer of the policy.

Coverage type and self paid codes; Many of the defined elements in a resource are references to other resources. Using these references, the resources combine to build a web of information about healthcare; ID assigned to the subscriber

Shelly Spiro Pharmacy HIT Collaborative
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Sequence of characters used to uniquely refer to an individual with respect to their insurance.

Robert C Dieterle On behalf of the Da Vinci Project
Draft USCDI V7

Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 

Narrative summary requesting an opinion, advice, or service from a clinician.
Examples include but are not limited to primary care referral to dermatology, dentistry, and acupuncture.

  • Logical Observation Identifiers Names and Codes (LOINC)
    • At minimum: Referral note (LOINC code 57133-1)
Swapna Abhyankar Regenstrief Institute, LOINC Document Ontology Subcommittee
Draft USCDI V7

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Findings of clinical tests.

Melissa Ayres SSA
Draft USCDI V7

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings.

Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG).

  • Logical Observation Identifiers Names and Codes (LOINC®)
Holly Miller, MD MedAllies
Draft USCDI V7

Data used to categorize individuals for identification, records matching, and other purposes.

Modifications, tools, technologies, and other supports necessary to access care.

  • SNOMED Clinical Terms (SNOMED CT) U.S. Edition
Grace Cordovano Enlightening Results
Draft USCDI V7

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Assessment of a patient’s physical, cognitive, or psychiatric disabilities.

Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS).

  • Logical Observation Identifiers Names and Codes (LOINC®)
Grace Cordovano Enlightening Results
Draft USCDI V7

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Directions for administering or taking a medication. 

Usage note: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper). 

Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications. 

Shelly Spiro Pharmacy HIT Collaborative
Draft USCDI V7

Data used to categorize individuals for identification, records matching, and other purposes.

Type of business that compensates for work or assigns work to an unpaid worker or volunteer. 

Examples include but are not limited to U.S. Army, cement manufacturing, and children and youth services.

  • Occupational Data for Health
Nedra Garrett CDC
Draft USCDI V7

Data used to categorize individuals for identification, records matching, and other purposes.

Type of work of a person. 

Examples include but are not limited to infantry, business analyst, and social worker.

  • Occupational Data for Health
Nedra Garrett CDC
Draft USCDI V7

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Statement of whether a medication has been consumed according to instructions. 

Examples include but are not limited to taking as directed, taking less than directed, and not taking.

  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition
Shelly Spiro Pharmacy HIT Collaborative
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Relationship of a patient to the primary insured person.

Mark Roberts Leavitt Partners
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Health insurance offering or package.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Sequence of characters used to uniquely refer to an insurance plan.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Mark Roberts Leavitt Partners
Draft USCDI V7

Data related to an individual’s insurance coverage for health care.

Presence or absence of healthcare insurance.

Mark Roberts Leavitt Partners
Draft USCDI V7

Provider-authored request for the delivery of patient care services.

 Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care.

Provider-authored request for end-of-life or life-sustaining care for a person who has a serious life-limiting medical condition.

Usage note: These are meant to follow a person regardless of when and where such an order might be needed (e.g., hospital, care facility, community, home). There are variations in requirements and names for portable medical orders based on jurisdiction.

Examples include but are not limited to POLST (Portable Medical Order for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and out-of-hospital DNR (do-not-resuscitate).

Grace Glennon on behalf of Joel Andress and CMS-CCSQ On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Draft USCDI V7

Data used to categorize individuals for identification, records matching, and other purposes.

Tribe or band with which an individual associates.

Laura Conn
Draft USCDI V7

Analysis of clinical specimens to obtain information about the health of a patient.

Categorical assessment of a laboratory value, often in relation to a test's reference range. 

Examples include but are not limited to high, low, critical high, and normal.

  • SNOMED Clinical Terms (SNOMED CT®) U.S. Edition
  • Health Level 7® (HL7) Code System ObservationInterpretation
Riki Merrick Association of Public Health Laboratories
Draft USCDI V7

Analysis of clinical specimens to obtain information about the health of a patient.

Sequence of characters assigned by a laboratory for an individual specimen. 

Example includes but is not limited to accession number.

Riki Merrick Association of Public Health Laboratories
Draft USCDI V7

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Evaluation of a patient's consumption of alcohol.

Examples include but are not limited to history of alcohol use, alcohol use disorder identification test, and alcohol intake assessment.

  • Logical Observation Identifiers Names and Codes (LOINC®)
Clem McDonald National Library of Medicine